Complaint Investigation Report

336426760-12-8-2022-18-AS-DMUN-CMHU5B-20221227141627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

11/05/2021 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20211105103544

Facility staff did not prevent resident from falling while in care.

Licensing Program Analyst (LPA) Jesse Gardner arrived to deliver the findings for the above complaint allegation. LPA met with Administrator Marlya Dunham. LPA toured the facility, interviewed staff and residents, and reviewed facility records.

An allegation was received stating facility staff did not prevent resident from falling while in care. Through interviews with S1 & S2 it was discovered that on 10/23/21 while S1 was in R1’s bedroom, R1 fell from the wheelchair. S2 heard the commotion and came into the bedroom to assist S1 with the resident. S1 stated R1’s lips were “bluish purple and that R1 was not responsive.” 911 was contacted and R1 was sent to the hospital as a result of the fall. A review of R1's records revealed that although R1 utilized a wheelchair to ambulate, her ability to ambulate was not dependent on caregiver assistance. An attempt to interview R1 was made but was unsuccessful due to R1’s cognitive abilities.

Based upon the investigation the allegation that facility staff did not prevent resident from falling while in care is unsubstantiated. R1 appeared to be having a medical emergency resulting in a spontaneous fall from the wheelchair. Staff was in the room and the time of the incident and responding immediately to R1. Therefore, based upon the investigation the allegation is unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was provided.

This is an amended version of the original report created on 1/3/2022.